Move United Insurance Program Application

Official Incorporated Member Organization Name:*

Official Address of Chapter*

Street Address City State / Province / Region ZIP / Postal Code

Name:*

Email*

Desired Coverage Start Date*

Please upload a current copy of your Commercial General Liability Insurance Policy:*

Maximum allowed on this server: 100MB

Max. file size: 64 MB.

Please upload a current copy of your Loss Run Reports for all policies held during the last 5 years:*

Maximum allowed on this server: 100MB

Max. file size: 64 MB.

What county and state will be the exclusive jurisdiction and venue in the event of a claim?*

Programming

Please provide the information requested below as accurately and completely as possible for insurance policy period for the next 12 months.

How many unique days of programming does your member organization expect to serve in a calendar year?*

Note: Count each day once, regardless of the number of programs being run in a day.

Total number of unique participants that your member organization expects to serve:*

Note: Count each participant once

Total number of unique volunteers that your member organization expects to use:*

Note: Count each volunteer once

Total number of unique employees that your member organization expects to use:*

Note: Count each employee once

List all sports to be conducted (ex: basketball, rock climbing, sled hockey, track & field):*

List all recreational activities (ex: bird watching, camping, fishing, yoga):*

List all fundraising events (ex: 5k walk & roll, concert, dinner & auction, wine tasting):*

List all community outreach activities (ex: clinics, demonstrations, expos, presentations):*

List all social events conducted (ex: dance, movie night, open house, potluck dinner):*

Does your chapter plan to add any additional activities in the next 12 months? Please describe:*

Is alcohol served at any of the activities conducted?*

Yes
No

Who serves the alcohol at these events?*

List the events where alcohol is served:*

Does your chapter conduct overnight activities?*

Yes
No

Does your chapter have lodging accommodations?*

Yes
No

Additional Policies

Additional information to help determine whether or not your organization is adequately insured:

Does your chapter own or rent vehicles?*

Yes
No

Does your chapter own any equipment? *Please note that any equipment owned is NOT insured under the Move United Group Commercial General Liability Policies.*

Yes
No

Does your chapter own any land/property? *Please note that any land owned is NOT insured under the Move United Group Commercial General Liability Policies.*

Yes
No

Does your chapter have Directors & Officers and Employment Practices Liability Insurance?*

No
Directors & Officers Liability Only
Employment Practices Liability Only
Yes, Both Directors & Officers and Employment Practices Liability

Move United Insurance Program Application

Programming

Additional Policies

Share